Adverse events that can occur when drugs are dispensed as the wrong
medications underscore the need for clear interpretation and better
communication between the doctors who write prescriptions and the pharmacists
who fill them. The FDA says that about 10 percent of all medication errors
reported result from drug name confusion.

"These errors are not usually due to incompetence," says Carol A. Holquist,
R.Ph., director of the Division of Medication Errors and Technical Support in
the FDA's Office of Drug Safety. "But they are so underreported because people
are afraid of the blame." Errors occur at all levels of the medication-use
system, from prescribing to dispensing, Holquist says, which is why those people
who receive the prescriptions must take action, too. "Everybody has a role in
minimizing medication errors," she says.

Medication errors can occur between brand names, generic names, and
brand-to-generic names like
Toradol and
tramadol. But
sometimes, medication errors involve more than just name similarities.
Abbreviations, acronyms, dose designations, and other symbols used in medication
prescribing also have the potential for causing problems.